Tricuspid Annuloplasty
Source: Tager R, et al. Am J Cardiol 1998;81:1013-1016.
After successful mitral valve or mitral and aortic valve surgery, some patients develop significant tricuspid regurgitation. Preoperative indications for tricuspid valve annuloplasty are unclear. Thus, Tager and associates evaluated 120 patients who underwent first mitral or mitral and aortic surgery by echocardiography. Patients with moderate-to-severe TR and tricuspid annulae greater than 30 mm in diameter were recommended to have annuloplasty. Of the 43 who had annuloplasty, 33 had significant TR and 10 had dilated annulae. At follow-up (mean, 57 months), significant TR persisted in five (12%), and none developed significant TR. Of the 77 who did not receive annuloplasty because of surgical decisions, 38 had dilated annulae or significant TR. Significant TR persisted (3) or developed (5) in eight (21%). Based on the results in the 10 who had a dilated annulus and had annuloplasty, the five patients who developed significant TR out of the 38 (13%) with dilated annulae and no annuloplasty could have had the development of TR prevented. Tager et al conclude that preoperative echocardiography demonstration of moderate-to-severe TR or a tricuspid valve annulus diameter greater than 30 mm are indications for performing tricuspid valve annuloplasty in patients undergoing mitral or combined mitral and aortic valve surgery.
The presence of significant TR (especially in the operating room after the left heart valve surgery has been completed) has always been a criteria for tricuspid valve surgery. However, this criteria is not sufficient, because some patients without significant TR perioperatively develop it later. Thus, criteria for prophylactic surgery on the tricuspid valve at the time of left heart valve surgery are needed. An older criterion was a right atrial pressure more than 15 mmHg preoperatively. With many patients going to surgery without a right heart catheterization, these data are often not available and were not presented in this paper. The authors' proposal of using a tricuspid valve annulus size larger than 30 mm as a criterion for tricuspid valve surgery is supported by their observational data and may be a reasonable approach since prospective controlled data are unlikely to be forthcoming. -mhc
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